Mr. Holmes is a Medical Student at the University of California, Riverside in Riverside, California. Ms. Limone is a Medical Student, Dr. Vassantachart is a PGY-2 Dermatology Resident, and Dr. Zumwalt is a PGY-4 Dermatology Resident, all at Loma Linda University in Loma Linda, California. Dr. Jacob is the Dermatology Section Chief and Professor of Dermatology, and Dr. Hirokane is the Dermatology Clinical Director and Assistant Professor of Dermatology, both at Loma Linda University and the Loma Linda VA Medical Center. Correspondence: Dr. Jacob (sharon.jacob@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Even in the hands of a trained dermatologist, dermoscopy has limitations. Featureless melanoma is a term applied to melanoma lesions bereft of classical findings on both naked eye examination and dermoscopy. Menzies, a dermatologic pioneer in dermoscopy, acknowledged this limitation in 1996 while showing that 8% of melanomas evaded dermoscopic detection. He proceeded to discuss the importance of clinical history in melanoma detection because all of the featureless melanomas exhibited recent changes in size, shape, and/or color.26 More recently, sequential dermoscopy (mole mapping) imaging has been implemented to successfully identify these lesions.27 Thus, dermoscopy cannot replace dermatologists trained in the art of visual assessment with honed clinical diagnostic acumen. Rather, dermoscopy is a tool to enhance the assessment of clinically suspicious lesions and aid diagnostic discrimination of uncertain pigmented lesions.
Conclusion
Primary care physicians are on the frontline of medicine and often the first to have the opportunity to detect the presence of melanoma. Notably, 52.2% of the 884.7 million medical office visits performed annually in the US are with PCPs.28 Despite the benefits, dermoscopy is not uniformly used by dermatologists in the US. Of dermatologists practicing for more than 20 years, 76.2% use dermoscopy compared with 97.8% of dermatologists in practice for less than 5 years. This illustrates an increased use in tandem with dermatology residencies integrating dermoscopy training as a component of the curriculum, showing the importance of incorporating dermoscopy into medical school and residency training for PCPs..29-31 Guidelines regarding dermoscopy training and dermoscopic evaluation algorithms should be established, routinely taught in medical education, and actively incorporated into training curriculum for PCPs in order to improve patient care and realize the potential health care savings associated with the early diagnosis and treatment of melanoma. Dermoscopic-teledermatology consultations present a viable opportunity within the VHA to expedite access to care for veterans and simultaneously offer evaluative feedback on lesions to referring PCPs, as skilled, dermoscopy-trained dermatologists render the diagnoses. Given the devastating mortality rate of melanoma, continued multidisciplinary education on identifying melanoma is of the utmost importance for patient care. Widespread implementation of dermoscopy and dermoscopic-teledermatology consultations could save lives and slow the ever-increasing economic burden associated with melanoma treatment, costing $1.467 billion in 2016.32
